One-Stage Urethroplasty for Strictures at a Rural Hospital
Winston Makanga1, Christian A Agbo2
1 St Mary’s Mission Hospital, Kenya
2 Jos University Teaching Hospital, Nigeria
Correspondence to: Dr. Winston Makanga, PO Box 1698, Embu, Kenya; email:email@example.com
Introduction: St Mary’s Mission Hospital manages many inflammatory and traumatic urethral strictures. Previously, we treated strictures with dilatation, but high recurrence and poor patient satisfaction necessitated adoption of reconstructive procedures since 2017. Objective: To review the scope, outcome and complications of urethroplasties using data collected prospectively. Methods: All cases of one-stage urethroplasty were included. Patient biodata and pre-operative adverse factors were collected and analyzed. Results: 23 male patients ranging in age from 24 to 74 years were studied: 9 strictures were inflammatory (40%), 9 were traumatic (40%), 3 (20%) were recurrent. Nineteen strictures were in the bulbar urethra (83%), 2 were cases of penile strictures and 1 case each of pan-urethral stricture and pelvic floor urethral distraction defect. Of the 23 procedures, 13 were simple anastomosis (57%), 5 were dorsal buccal mucosa graft (BMG) urethroplasty (22%), 2 were cases of non-transecting anastomotic urethroplasty, and 1 case each of ventral BMG urethroplasty and Johansson’s and Kulkarni’s panurethroplasty. The overall complication rate was 40% (9 patients). Four patients (17%) had recurrence; 2 had fistula and 1 case each of persistent UTI, erectile dysfunction and periurethral abscess. Three of the four recurrences had undergone BMG urethroplasty. All cases of simple anastomosis had no recurrence. Conclusion: Our centre has embraced diverse urethroplasties for a wide scope of patients. This study found a significant complication rate for substitution urethroplasties, suggesting a need for careful patient selection and an improvement in technique.
Key words: Stricture, Urethroplasty, One-stage, Complications, Outcome
Ann Afr Surg. 2019; 16(1):16–19
Conflicts of Interest: None
© 2019 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.
Urethral stricture is a progressive narrowing or occlusion, or loss of distensibility of any part of the urethra secondary to periurethral spongiofibrosis (1). The etiology is either infective or trauma (2). Previous transurethral endoscopic surgery is now a major cause of post-traumatic strictures with a pooled range of 2.2–11.6% (3, 4). Postgonococcal urethritis with complicating strictures has been on the decline with the advent of appropriate antibiotics (5–7).
Urethral bouginage/sounding has historically been used to treat these strictures, partly because of its low cost and the ease of carrying out the procedure. These measures are however short term at best, and at worst worsen the strictures, in both length and breadth (8). Urethroplasty is the only potentially curative modality. These methods are offered only by specialized urethral surgeons. In Kenya, such
specialists are few and are found mainly in large referral
hospitals located in the main cities (9,10). The two main types of reconstruction are anastomotic and substitutional; both aim to produce a high-caliber, stable and compliant urethra while resolving obstructive symptoms and related sequelae (11). Anastomotic reconstructions rely on apposition of well-mobilized, tension-free urethral ends. Substitution techniques rely on introduction of either free tissue (buccal mucosa) or of flaps obtained from elsewhere, to bridge urethral defects. Most flap techniques are complex with a steep learning curve, and are mostly two-stage procedures. Such complex procedures increase the possibility of complications. Two-stage procedures require close follow-up and introduce a burden to the patient of taking care of the initial surgical site. A second admission and surgery also increase the overall cost. Techniques such as the two-stage
Bracka urethroplasty have potentially poor outcomes because the initial buccal mucosal graft shrinks and becomes desiccated by the time 6 months elapse in time for the second-stage surgery. One-stage repair was historically suited for solitary, short (sub-centimeter) or multiple contiguous strictures. The indications have now been broadened to include longer strictures including panurethral strictures (12). One-stage procedures offer the benefits of reducing overall cost, better tolerance and reducing the general risk of anesthesia and surgery.
Urethral stricture constitutes significant morbidity at St Mary’s Hospital, Kenya. A large number of our patients come from Narok, a region with a high number of post-gonococcal urethritis and urethral stricture. These patients present with obstructive lower urinary symptoms, recurrent urinary tract infection, periurethral abscess and/or watering can phenomenon. At St Mary’s Hospital, obstructing symptoms have hitherto been resolved through dilatation (metal sounding). This has been occasioned by the cost implication, lack of a reconstructive urologist and rapid symptomatic relief of the intervention. The recurrence of symptoms has however been unacceptably high, ranging from as short as one month to three months. This recurrence could be attributed to the complex nature of some of these inflammatory strictures. A patient also has a potential likelihood of requiring this procedure for life.
We started carrying out urethroplasty in 2017, as an intervention with the potential to cure stricture disease as well as reduce physical deformity, prolonged follow-up and repeat procedures. This informed our decision to adopt one-stage urethroplasty as our procedure of choice. We audited our safety procedures and outcomes at this early stage to determine if our interventions were within internationally acceptable standards.
All patients who underwent one-stage urethroplasty were entered into the study. One-stage urethroplasty is a reconstructive procedure for primary or recurrent urethral stricture that aims to achieve urethral continuity and patency without requiring a second procedure and includes simple anastomotic urethroplasty, non-transecting anastomotic urethroplasty, buccal mucosal graft (ventral, dorsal and long dorsal panurethral graft), and complex bulboprostatic anastomosis with or without inferior pubectomy. Excluded from this audit were urethral dilatations, suprapubic diversions, DVIU, hypospadias reconstruction.
All patients were operated in the exaggerated lithotomy under either spinal (no BMG required) or general anesthesia (BMG required). A detailed description of the individual procedures as done in our centre follows;